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Based on observation, interview, and documentation reviewed by State Fire Marshal staff, the facility failed to assure staff on the 4th Floor Behavioral Health Unit had a means of opening the doors in the event of a fire or other emergency situation. Observations revealed that multiple staff failed to have keys or a card to unlock the locked exit doors and during a fire alarm test, the doors did not automatically unlock, which was confirmed during interview with facility Maintenance staff. This deficient practice placed all patients, staff and visitors on the Behavioral Health Unit at risk of serious injury, resulting in the Condition of Participation for Physical Environment not being met. See CMS 2567 - Life Safety Code deficiency statement, Tag K-0222.

On 9-24-18 at 4:17 pm, this deficient practice was determined to be of immediate jeopardy (IJ).
On 9-24-18 at 5:35 pm, the facility immediately implemented a fire watch on the fourth floor Behavioral Health Unit and started to notify staff of the fire watch. Due to the measures put in place, this abated the IJ.

NFPA Standard:
2012, NFPA 101, 18.2.2.2.5.1
Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 18.2.2.2.6.

18.2.2.2.6
Doors that are located in the means of egress and are permitted to be locked under other provisions of 18.2.2.2.5 shall comply with both of the following:
(1) Provisions shall be made for the rapid removal of occupants by means of one of the following:
(a) Remote control of locks from within the locked smoke compartment
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all times
(2) Only one locking device shall be permitted on each door.